185 - med surg exam 2 Flashcards
When a client with a second degree burn injury in the acute stage of recovery, which finding would the LPN report immediately to the registered nurse?
A) Urine output of 70 mL/hr
B) Foul oder from the wound
C) Client reports pain 3/10
D) Client reporting no bowel movement for the past 2 days
B) Foul oder from the wound
RATIONALE: Foul oder may indicate infection and should be reported immediatly to the RN for a follow up
Tissue injury caused by thermal/chemical/ect. burns
Severity is based on size, debth, location, age, gender, health status, & mechanism of injury
Classified by size & debth of tissue injury
* Partial or full thickness
* reevaluate frequently
* Size often defined as % of area effected (Wallace Rule of 9)
Leading cause of accidental death
Burns
Affects ONLY epidermis - mildest
S/S:
* Pink/red
* Painful, minor swelling
* Dry w/o blisters
* Blanches
* No vesicles
Healing time:
* 3-6 days
* Superficial layer overskin may peel off in 1 or 2 days
Ex: Sunburn
Superficial Burn (1st Degree)
Affects epidermis & dermis
S/s:
* Painful
* Large, moist, weepy blister
* Pale, pink, red
Ex: severe sunburn, large blister
Superficial partial thickness burn (2nd degree)
Exposed dermis
* Skin, fat, muscle
S/s:
* Large, thick walled blister/edema
* weeping, cherry red
* Painful, sensative to cold air
Tx:
* Hospitalization
* monitor for shock
* Keep covered
Deep partial thickness burn
Involves epidermis, dermis, & underlying tissues including fat, muscle, & bone
S/s:
* Dry, leathery, eschar
* May be red, brown, black, or white
* Lacks sensation
Tx:
* Hospitalization
* monitor for shock
* Keep covered
Full thickness burn
What are the percentages of each body part involved in the rule of nine?
Head (Front & back)
Arms (Front & back)
Abd (2 sections - upper/lower (Front & back))
Legs (Front & back)
Groin (Front & back)
Head (Front & back) - 4.5%
Arms (Front & back) - 4.5%
Abd (2 sections - upper/lower (Front & back)) - 9%
Legs (Front & back) - 9%
Groin (Front & back) - 1%
Predicts the probability or morality d/t burns
Baux score
When is fluid resuscitation the most critical in a burn pt?
24-48 hrs after injury
I/O’s strictly monitored to prevent shock
What is the most common skin infection for a burn patient that is found in the U.S?
Methicillin-resistant staphylococcus aureus (MRSA)
Releases chemicals that cause increased capillary permeability
Permits excess Na to enter the cell & allows K to escape into the extracellular compartment
Shift causes edema & decreases cardiac output, & decline in blood volume (Olguria, hypovolemic shock)
* 18-36 hrs after injury, capillary permeability normalizes & reabsorption of edema fluid begins. Cardiac o/p normalizes & increases to meet increased metabolic demands
Decreased blood flow a ileus may occus
Stress ulcer may occur (Curling ulcer)
Pathophysiology of Burn injuries
What is the most common skin infection for a burn patient that is found OUTSIDE of the U.S?
Acinetobacter
What lab should you draw for a military pt who has returned to the U.S for treatment?
Culture on admission to rule out any infection (Acinetobacter / MRSA)
Begins when burn starts & ends when fluid shifts stabilize
* First 12-48 hrs critical
S/s:
* Hemoconcentration (Increased Hct)
* Acute renal failure (ARF), olguria
* Hyperkalemia, hyponatremia
* Hypovolemic shock
* Metabolic acidosis
* Risk of cardiac dysrhythmias
Tx:
* ABCs, ABGs
* Start IV (PIV/central)
* Insert cath. & NGT, tetanus prophylaxis
* Pain managment/assessment & tetanus
* Clean/debride wounds, topical antibiodics
* Blood for baseline blood studies (Hct, electrolytes)
* Assess for smoke inhalation injury - intubate if needed
* Hydrotherapy (softens eschar), escharotomy
* ROM, skin graft
Emergent / hypovolemic stage of burn injury
(1st of 3 stages of burn injuries)
Begins 48-72 hrs after fluids stabilize
* Some marked when all but 10% of burn wounds are closed or until all wounds are closed
S/s:
* Hemodilution (decreased Hct)
* CHF risk
* Metabolic acidosis
* Hypokalemia, hyponatremia
* Circulatory overload / hypervolemia (Main concern)
* Polyuria (kidney problem - Insert fowly cath)
Acute/Diuretic stage of burn injury
(2nd of 3 stages of burn injuries)
Goal: Prevent infection & return pt to “normal”
* Can take months
Overlaps w/ acute stage
* Starts when pt is stable
PT/OT begin tx
Interventions:
* Restore independence
* Adjusting to body image
* Preventing contractures
* Coping
Rehabilitation stage of burn injury
(3rd of 3 stages of burn injuries)
Which burn may blister, peel & heal w/ minimal long-term effects?
A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness
Chpt 57 pg 1165
A) Partial-thickness
Which burn is often covered by a thick, leathery layer of burned tissue/eschar that shelters microorganisms & inhibits healing?
A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness
Chpt 57 pg 1165
B) Full-thickness
Removal of debris & necrotic tissue from a wound
* Eschar must be removed or healing will not take place
Types:
* Surgical excision: Escharotomy
- Mechanical: Removing eschar/ necrosis w/ scissors/ forcepts
- Enzymatic: Use of topical medications containing enzymes capable of dissolving necrotic tissue. (Cause pain & bleeding)
Debridement
What is the goal of wound care after a burn injury?
Promote healing
Prevent infection
Controll heat loss
Retain function
Minimize disfigurement
What are the 2 standard wound care treatments for patients w/ burns?
Open care method:
* Topical antimicrobials but no dressings
* Less restrictive & simpler but provides increased opportunity for loss of fluid & heal through wounds surface
Closed care method:
* Topical antimicrobials but covered by dressings
Examples of Topical medications:
* Silvadiazine (Silvadene)
* Mafenide acetate (Sulfamylon)
What is the preferred solution for burn patients?
Lactated Ringers (LR)
Where would a LPN start an IV?
Peripheral IV (PIV)
TIP: LPN can insert IV 3in into AC and below
Surgical procedure done by making an incision through the eschar to relieve underlying pressure, measuring the pressure in the compartment, closed space nerves, muscle tissue, & blood vessels
Used to relieve circulatory construction
Escharotomy
A burn covered by the pts own skin
* preferred sites are thigh or butt removed by dermatome (tool used to remove graft)
Autograft
(skin graft)
A type of skin graft applied to a thin layer of skin
May be an intact layer of skin or meshed graft
* Meshed grafts have multpile tiny slits to allow skin to be stretched to cover a large area
Split-thickness graft
A type of skin graft used for deep burns to face, neck, & hands
Include subq tissue & skin
Cosmetically provied better results
Full thickness graft
What are some nursing interventions for a pt w/ a skin graft?
Assess site for bleeding
Immobilization of affected area for 3-7 days to ensure attachment of the graft
Remove dressings and allow wound to air dry 24 hrs after surgery - Can use heat lamp to dry area
* While site dries, a fine-mesh gaze or Zeroform will lift off of the skin
What vitals s/s should you notify the HCP immediatley for in a client w/ burn injuries?
Take vitals first & report:
* Restlessness, Tachypnea (Hypoxia)
* Bounding pulse, HTN (Fluid volume excess)
* Tachycardia, hypotension (Hypovolemia)
* Fever, Tachycardia (Infection)
What intervention should be done ASAP during an inital assessment of a stable pt w/ a burn injury?
Height & weight
Occurs w/ flame burns or from being trapped in an enclosed space filled w/ smoke
Pts can have pulmonary edema resulting in resp. failure
S/s:
* Facial burns
* Redness, swelling of pharynx
* Restlessness, Tachypnea (Hypoxia)
* Dyspnea, sooty sputum
* Death
Interventions:
* Protect airway (intubate) and evaluate for resp. distress syndrome
* Apply O2
* pulmonary function studies done before discharge to complete lung function
Smoke inhalation
Carbon monoxied displaces O2 on _____ , so the blood is unable to transport O2 into the tissues
A) Hgb
B) Hct
C) WBC
D) platelets
A) Hgb
What type of pain meds would you give to a burn pt?
Morphine, fentanyl, & other opioids
* Pre-medicate priot to any procedure (Required)
What do the letters stand for in R.A.C.E?
R: Rescue
A: Alarm
C: Contain fire
E: Extinguish/ Evacuate
What do the letters in P.A.S.S stand for when operating a fire extinguisher?
P: Pull
A: Aim
S: Squeeze
S: Sweep
2 Types:
* Aesthetic (cosmetic) procedures: Performed to improve apperance
- Reconstructive procedures: Performed to correct abnormalities/ disfigured scars
Ex:
* Rhytidectomy (facelift): Remove wrinkles & tightens sagging tissue
- Blepharoplasty: Removal of excess tissue arround the eyes imparing vision, aesthetic procedure
- Chin implants: Done by placeing a prosthesis to correct a receding chin
- Rhinoplasty: Nose job, alters shape/size
- Abdominoplasty: Excess skin & adipose tissue are removed & abd. muscles are tightned
- Breast augmentation: Breast enlargment
- Breast reduction
Plastic surgery
What is the purpose of a reconstructive procedure?
Repair disfigured scars
Restore body contours after radical surgery (Mastectomy)
Restore features damaged from trauma/disease
Correct developmental defects
How could you educate a burn patient?
Practice good hygiene & avoiding others w/ infections
Eat 6 small frequent meals a day plus supplements
* Make sure to eat all food on plate
Change positions, exercise, & use splints to help prevent stiffening of the joints, skin breakdown, & blood clots in legs
Pain managment
* Contact HCP if pain is uncontrolled
Protect grafts from pressure & shearing
Clothing, make-up, hairpieces, & prostheses can be used to conceal scars & improve apperance
Adaptive devices are avalible to compensate for disabilities
Rehabilitation resources will be provided once the acute phase has passed
